OBJECTIVE: Optimal surgical management of the aortic arch for acute type A aortic dissection remains contentious. We assessed clinical outcomes after total arch replacement and proximal aortic repair (ascending aortic ± hemiarch replacement) for acute type A aortic dissection. METHODS: All patients surgically treated for acute type A aortic dissection at our institution between 1992 and 2021 were included. Study end points included all-cause mortality, distal aortic reintervention, stroke, and malperfusion syndrome. RESULTS: A total of 357 patients underwent surgery for acute type A aortic dissection
76 (21.3%) received total arch replacement, and 281 (78.7%) received proximal aortic repair. The frequency of total arch replacement increased over time ( CONCLUSIONS: In-hospital mortality after acute type A aortic dissection decreased over time despite the implementation of an aggressive approach to the dissected aortic arch. Long-term survival appears favorable after total arch replacement, but remains contingent on early postoperative survival. The surgical approach should be based on the patient's clinical presentation, while considering total arch replacement in patients at risk of aortic arch reinterventions.